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Complex ophthalmic surgical cases often require specialised anaesthetic input. This may include patients having repeated ophthalmic procedures, long and difficult cases, and those potentially requiring specialist intravenous drug therapy, such as intravenous steroids, acetazolamide or mannitol. An anaesthetist of appropriate experience should have dedicated responsibility for operating lists containing such complex cases.

Patients requiring anaesthesia who are systemically unwell should be optimised as far as reasonably practicable beforehand.³⁵It is extremely rare for ophthalmic surgery to be so urgent that remedial measures cannot be taken. Arrangements for appropriate perioperative medical care should be made, with specialist input from other services as required.

Protocols should be in place for the transfer of patients from isolated units who become ill unexpectedly. They should be moved safely and rapidly to a facility which provides an appropriate higher level of care.¹²

Where necessary, critically ill patients should be anaesthetised in an emergency theatre suite, taking specialist personnel and equipment to the patient, rather than vice versa.

When the specialist equipment cannot be moved, all necessary emergency equipment should be immediately available and transfer arrangements to a high dependency or intensive care setting should be in place.

Sharp needle based blocks (e.g. peribulbar or retrobulbar block) should only be administered by medically qualified personnel, because of the increased risks of life-threatening complications.2 Intravenous access should be established prior to performing sharp needle blocks and also for any patient deemed to be at high risk due to severe comorbidity.²

All modes of ophthalmic local anaesthesia may result in complications.²²Practitioners should be fully aware of these risks and should ensure that they know how to avoid and recognise complications. They should also be immediately available and able to safely and effectively manage problems when they do occur.

Patients exhibit extremely wide variation in response to drugs used for sedation. It is difficult to and undesirable to have to manipulate the airway of an unpredictably over-sedated patient during surgery, and so administration of intravenous sedation during ophthalmic surgery should only be undertaken by an anaesthetist whose sole responsibility for the duration of the surgery is to that patient.²

Patients do not need to be starved when sedative drugs are used in low doses to produce simple anxiolysis. Patients should follow fasting guidelines as for general anaesthesia when deeper planes of sedation are anticipated or sedative infusions employed.^_27,37,38

Hospitals should use the training opportunities available in ophthalmic anaesthesia to facilitate anaesthetists in training's acquisition of the learning outcomes of the RCoA 2021 Curriculum.³⁹